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Rheumatoid Arthritis Nursing Guide

Content Contributor: Edward Bartels, RN, BSN, MICN 

Overview: Rheumatoid Arthritis

This course is intended as a Quick Reference for Rheumatoid Arthritis and will provide an overview as well as nursing considerations utilizing the nursing process.

Rheumatoid Arthritis Etiology and Epidemiology

Unlike the wearing and tearing damage from osteoarthritis, rheumatoid arthritis affects the synovial joint linings (Mayo Clinic, 2021). The inflammatory nature of rheumatoid arthritis brings about synovitis, or inflammation of the synovium, the connective tissue lining inside the joint capsule. Rheumatoid arthritis presents as one of three types:

  • Symmetric
  • Relapsing
  • Destructive

Common characteristics of rheumatoid arthritis comprise:

  • Higher prevalence in females by two to three times
  • Typical appearance between the ages of 30 and 60
  • Most common form of inflammatory arthritis
  • Typically involves:
    • Three or more fingers
    • Wrist
    • Other joints
  • Destructive arthritis leading to musculoskeletal disability
  • Potential extraarticular complications appearing in primarily seropositive individuals include:
    • Rheumatoid nodules
    • Dermal vasculitis
    • Sjogren syndrome
    • Felty syndrome
    • Interstitial lung disease
    • Pericarditis
    • Neuritis
    • Amyloidosis
    • Hypothyroidism

Causes are unknown but believed to be potentially from a combination of genetic and environmental factors:

  • Smoking and other bronchial stressors
  • Infectious disease such as:
    • Epstein bar
    • Cytomegalovirus
    • Proteus species
    • Escherichia coli
  • Familial history
  • Gene susceptibility
  • Obesity
  • Periodontitis
  • Coffee consumption
  • Silica exposure

The exposure of a genetically predisposed individual to certain environmental stressors is thought to create an autoimmune response leading to the rheumatoid condition.

Rheumatoid arthritis reportedly affects an estimated 1.5 million adults in the U.S. (DynaMed, n.d.). Incidence rate annually is 41 cases per 100,000 men and 36 per 100,000 women.

Risk factors for rheumatoid arthritis originate from:

  • Familial history
  • Genetics
  • Environmental impacts

Rheumatoid Arthritis Diagnosis

Determining the presence of rheumatoid arthritis is guided by the criteria for diagnosis from the American College of Rheumatology/European League Against Rheumatism (DynaMed, n.d.) 

Assessment findings include:

  • Synovitis in multiple joints
  • History of long-standing disease
  • Multiple periarticular erosions
  • Joint involvement
  • Abnormal autoantibody serology results
  • Elevated erythrocyte sedimentation rate
  • Changes in reactive protein results

Diagnostics strive to identify individuals with rheumatoid arthritis early for therapy and protection from erosive changes. Treatment regime is based on baseline disease activity.

The physical exam looks for:

  • Observable osteo-deformities
  • Range of motion and gait abnormalities
  • Joint aspiration
  • Pain sites

Laboratory tests for rheumatoid arthritis include:

  • Rheumatoid factor
  • Cyclic citrullinated peptide antibodies
  • Erythrocyte sedimentation rate
  • C-reactive protein
  • CBC with differential
  • Metabolic panel

Imaging used to diagnose rheumatoid arthritis include:

  • Magnetic resonance imaging
  • Ultrasound
  • CT scan

Management

Referral to a rheumatologist should be expedited. Initiation of disease-modifying antirheumatic medications, alone or in combination, should begin once diagnosis is achieved and infectious disease screening is done.

Treatment includes:

  • Conventional non-biologics (first line)
    • Methotrexate (Otrexuo™)
    • Leflunomide (Arava®)
    • Sulfasalazine (Azulfidine®)
    • Low dose corticosteroids (Deltasone®)
  • NSAIDs (Motrin®, Aleve®)
  • Tumor necrosis factor inhibitor (Enbrel®, Remicade®, Humira®)
  • Primary treatment target is clinical remission
  • Permitting low disease activity may be appropriate for longstanding disease or comorbid states
  • Consider therapeutic adjustment every 3 months
  • Medication choices determined by disease activity and success of previous medications

Rheumatoid Arthritis Nursing Considerations

Use the nursing process to develop a plan of care for individuals. The nursing assessment rheumatoid arthritis, diagnoses, interventions, expected outcomes, and education for rheumatoid arthritis are listed below.

Assessment

Assess for signs and symptoms, such as:

  • Risk factors
  • Pain
  • Familial
  • Genetics
  • Integumentary
  • Pain sites
  • Joint deformity
  • ROM and gait
  • Emotional state
  • Energy levels
  • Social functioning
  • Physical functioning

Rheumatoid Arthritis Nursing Diagnosis/Risk For

  • Acute pain related to rheumatoid arthritis as evidenced by:
    • Reports of pain
    • Distraction
    • Guarding
    • Autonomic responses
  • Risk for infection related to decreased secondary defenses and immunosuppression as evidenced by:
    • Fever
    • Malaise
    • Abnormal lab values
    • Need for antibiotic therapy
  • Anxiety related to the condition as evidenced by:
    • Elevated vital signs
    • Activity level
    • Tone of voice
    • Nervousness
    • Diaphoresis
    • Muscle tension
  • Deficit in knowledge of symptom prevention and condition management as evidenced by:
    • Request for information
    • Verbalization of problems
    • Presence of preventable complications
  • Impaired physical mobility, related to pain and discomfort as evidenced by:
    • Decreased purposeful movement
    • Impaired coordination
    • Reduced muscle strength and mass

Interventions

  • Promote relaxation techniques.
  • Assist or administer medication as ordered.
  • Assess all systems for signs of infection.
  • Monitor temperature regularly.
  • Encourage verbalization and sharing of feelings.
  • Discuss side effects of treatments.
  • Assist with physical and occupational therapy routines.

Expected Outcomes

  • Reports adequate pain control
  • Maintains positions of function and avoidance of contractures
  • Preserves muscular strength and joint ROM
  • Verbalizes understanding of disease process and treatment regimes
  • Remains afebrile and free from infection
  • Expresses feeling openly and honestly
  • Continues normal life activities
  • Verbalizes understanding of side effects and measures to correct

Individual/Caregiver Education

  • Diagnosis and treatments
  • Signs of potential complications
  • Support groups available
  • Nutrition and diet
  • Lifestyle changes
  • Call the provider or seek immediate medical care for:
    • Pain or worsening symptoms
    • Medication side effects
    • Fever
    • Loss of joint mobility
  • Medications they are prescribed
  • Encourage the individual to follow-up with healthcare provider as recommended

Rheumatoid Arthritis: A Chronic Disease CE Course

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Additional Information

Content Release Date 

4/1/2022

Content Expiration

12/31/2025

Content Contributor

The content was created by Edward Bartels, RN, BSN, MICN Ed has over 30 years of clinical and teaching experience, and his areas of expertise are emergency and critical care, skilled nursing, behavioral health, occupational health, and safety, and home care. Ed served in several senior nursing leadership roles including: Emergency Services Director, Physician Practices Director, and Administrative Director of Nursing at the executive level. Ed is certified in LEAN efficiency fundamentals and tactics, which he has successfully deployed over the years in multiple settings resulting in cost savings, improved quality, and patient safety. Ed is a certified clinical nursing instructor in North Carolina. He earned his Diploma in Nursing from St. Vincent's School of Nursing in Staten Island, New York, in 1990 and Bachelor of Science in Nursing from the University of North Carolina, Greensboro in 2006. Ed is retired from the U.S. Coast Guard with 34 years.

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